Daphne Cherry · Prevention of Future Deaths report

On the 1/3/2016 I commenced an investigation into the death of Daphne Cherry. The investigation concluded at the end of the inquest on the 9th March 2017. The conclusion of the inquest was a narrative conclusion. The medical cause of death was 1A bronchopneumonia and 2 gastric erosions and bladder cancer.

Daphne Cherry was an 83 year old lady with a significant medical history including diabetes, hypertension and dementia. She had been a resident at a Care Home in Cheltenham since February 2015. At the beginning of February 2016 she had suffered an episode of diarrhoea and vomiting. Thereafter her appetite decreased. On the 17th February she was diagnosed with a urinary tract infection, and her GP prescribed antibiotics. That prescription was further extended on the 19th. Over the weekend of the 20th and 21st February 2016, staff at the care home were aware that Daphne was suffering an infection, taking antibiotics, and that her fluid intake was lower than her recommended level. Staff and family members were encouraging her to take sips of water. However when her fluid intake continued to decline staff did not escalate the matter, and no medical review was sought until after 6am on Monday 22nd February. Paramedics attended, and Daphne was transferred to hospital where a severe kidney injury was diagnosed. She was severely dehydrated, and appropriate treatments were instituted. Daphne’s condition steadily deteriorated and she passed away at 23.15 hours on the 22nd February 2016. The post mortem has identified a natural cause, bronchopneumonia as the final factor that caused Daphne’s death, in the context of gastric erosions and bladder cancer. The likelihood of Daphne developing bronchopneumonia was increased due to her age, the fact that she had developed an infection, and that she had sustained an injury to her kidneys. There are several possible causes for the latter injury including a lack of fluids, and the medications Daphne was taking.

(1) Whether staff at the Care Home are able to identify when a medical concern should be escalated and a medical review sought.